Pharmacy Temperature Excursion Response Log

Document pharmacy refrigerator temperature excursions, identify affected products, record pharmacist review, and capture corrective actions taken.

Excursion Details

• Date of Excursion
• Time Excursion Was Discovered
• Storage Unit
• Excursion Start Date and Time
  Enter if known from monitoring records.
• Excursion End Date and Time
  Enter when the unit returned to the acceptable range, if known.
• Estimated Excursion Duration (hours)
• Observed Temperature Range
• Approved Storage Range

Affected Product Assessment

• Were any products affected?
• Affected Product Name(s)
  List the medication or product names only if products were affected.
• Lot Number(s)
  Provide lot numbers if available and relevant to disposition.
• Expiration Date(s)
  Include expiration dates if needed for review.
• Quantity Affected
• Immediate Product Status

Pharmacist Review and Decision

• Pharmacist Review Completed
• Pharmacist Name
  Collect only if needed for internal review and authorization.
• Pharmacist Decision
• Decision Rationale
  Summarize the basis for the decision, including any reference to stability data or policy.
• Manufacturer Contacted
• Consultation Reference or Case Number
  Enter if a manufacturer, wholesaler, or internal case reference was used.

Corrective Action and Follow-Up

• Corrective Actions Taken
• Root Cause Summary
  Briefly describe the likely cause if known.
• Preventive Actions / CAPA
  Describe any follow-up actions to prevent recurrence.
• Follow-Up Required
• Follow-Up Owner
• Follow-Up Due Date

Submitter Acknowledgment

• Submitter Name
• Submitter Role
• Submitter Phone
  Optional contact number for follow-up.
• I confirm the information provided is accurate to the best of my knowledge.